Discipline of Psychiatry, Northern Clinical School, University of Sydney, Sydney, NSW, 2000, Australia.
Department of Academic Psychiatry, Northern Syndey Local Health District, St Leonards, NSW, 2065, Australia.
CNS Drugs. 2019 Apr;33(4):301-313. doi: 10.1007/s40263-019-00609-3.
Our current conceptualisation of mixed states, defined as co-occurring manic and depressive symptoms, is unlikely to advance our knowledge or inform clinical practice. Episodes of mixed states can no longer be coded in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and the 'mixed features specifier' fails to capture the most common mixed state presentations. This reflects a lack of understanding of both the importance of mixed states and their underlying pathophysiology. Indeed, research into the nature of mixed states is scarce and uninformative, and most clinical practice guidelines fail to provide advice regarding their management. In this paper, we proffer a reconceptualisation of mixed states that provides a framework for informing clinical practice and research. It is based on the ACE model, which deconstructs mood disorders into three domains of symptoms: activity, cognition, and emotion. Symptoms within each domain vary independently over time and in different directions (towards either excitation or inhibition). By deconstructing mood disorders into component domains, mixed states can be explained as the product of different domains varying 'out of sync'. In most cases, the aetiology of mixed states is unknown. Alongside such idiopathic mixed states, we describe three potential causes of mixed states that are important to consider when formulating management: transitions, ultradian cycling, and treatment-emergent affective switches. In addition to providing guidance on the identification of various kinds of mixed states, we discuss practical strategies for their management, including the monitoring of ACE domains and functioning, to inform the use of psychoeducation and lifestyle changes, psychotherapy, pharmacology, and electroconvulsive therapy.
我们目前对混合状态的概念化，定义为同时存在躁狂和抑郁症状，不太可能增进我们的知识或为临床实践提供信息。DSM-5 不再对混合状态发作进行编码，而“混合特征特征”未能捕捉到最常见的混合状态表现。这反映了我们对混合状态的重要性及其潜在病理生理学的理解不足。事实上，对混合状态本质的研究很少且没有提供信息，大多数临床实践指南未能就其管理提供建议。在本文中，我们提出了一种对混合状态的重新概念化，为指导临床实践和研究提供了一个框架。它基于 ACE 模型，将心境障碍分解为三个症状领域：活动、认知和情绪。每个领域内的症状随时间独立变化，方向也不同（朝向兴奋或抑制）。通过将心境障碍分解为组成领域，可以将混合状态解释为不同领域“不同步”变化的产物。在大多数情况下，混合状态的病因尚不清楚。除了这种特发性混合状态之外，我们还描述了混合状态的三个潜在原因，在制定管理方案时需要考虑：转变、超日周期和治疗诱发的情感转变。除了提供对各种混合状态识别的指导外，我们还讨论了其管理的实用策略，包括对 ACE 领域和功能的监测，以告知使用心理教育和生活方式改变、心理治疗、药理学和电惊厥治疗。
